Previously, we carried out a comprehensive inspection of this service on 13, 16 and 17 October 2017. At that inspection the service was rated 'Good' overall and there were no breaches of the regulations. After that inspection we received concerns in relation to staffing levels, the safety of people and the treatment received by people living at the home. As a result, we undertook another fully comprehensive inspection of Pavilion Court on 15 and 16 October 2018 to look into those concerns.

At this inspection we identified a number of concerns and shortfalls which resulting in a breaches of regulations 9 (person centred care), 10 (dignity and respect), 12 (safe care and treatment), 17 (good governance) and 18 (staffing).

The provider had not adequately assessed the risks to the health and safety of people using the service, staff did not provide person centred care, staff demonstrated unsafe practice, people were not always treated with dignity and respect, people’s support needs were not met, staffing levels were not adequate to meet people’s needs and the governance of the service did not fully assess the quality of the care provided. During the inspection we raised four safeguarding alerts to the local authority due to concerns about the standard of care people were receiving. Following our site visit we also received additional whistleblowing concerns which we also shared with the Local Authority Safeguarding team.

You can see the action that we have asked the provider to take at the back of the full version of this report.

Pavilion Court is 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Pavilion Court can accommodate 75 people in one adapted building and on the date of this inspection there were 56 people living at the service. People received a mixture of residential and nursing care. Some people living at the home had a diagnosis of dementia or had fluctuating capacity.

Staff had received initial training around safeguarding vulnerable adults’ but we noted that this training had not been refreshed or completed by the majority of staff. Staff had received supervision sessions around safeguarding and could tell us what action they would take if they were concerned or witnessed any form of abuse. People told us they felt safe living at Pavilion Court Care Home and relatives agreed with these comments. There were policies and procedures in place to help keep people safe from abuse, these included the provider’s safeguarding vulnerable adults’ policy and information for people and relatives about reporting abuse.

We observed and were told by people that there were not always enough staff to support people when needed. The service assessed dependency needs for people which we reviewed as well as the staffing rotas for four weeks. The service frequently used agency staff but this had begun to reduce as new staff had been employed by the service. We observed that staffing levels on the second day of inspection were appropriate to support people. Staff, people and residents told us that at times there were not enough staff to support them, especially at night.

Staff did not always treat people with dignity and respect. We found records of people’s daily care in communal areas. Some people told us that they did not always know who was supporting them and that they did not receive the support they needed, when they needed it. Some people told us the staff spoke nicely to them and were caring. We observed people enjoyed positive relationships with some staff. We saw staff asking people for consent when supporting and asking for people's choices for meals and drinks.

There was an infection control policy in place at the home but this was not always followed by staff. Communal lounges and dining rooms were

This inspection took place on 13, 16 and 17 October 2017 and was unannounced. This meant that the provider and staff did not know that we would be visiting.

We last inspected the service on 24 and 30 August 2016. We identified two breaches of our regulations. These related to person centred care and good governance. We asked the provider to take action to make improvements and this action has been completed.

At this inspection, we found that improvements had been made and the provider had ensured good outcomes for people in each of the five key areas we inspected. Pavilion Court provides care and accommodation for up to 75 people, some of whom have a dementia related condition. There were 41 people living at the home at the time of the inspection.

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People, relatives and staff were positive about the changes the registered manager had implemented. Staff informed us they were happy working at the home and morale was good. We observed that this positivity was reflected in the care and support which staff provided throughout the day.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. There was one ongoing safeguarding allegation which the registered manager was investigating.

An electronic medicine system was in place to manage medicines. There had been a number of medicines errors prior to our inspection. The registered manager had fully investigated these and was liaising with their pharmacy supplier. Several people had certain medicines administered via a patch applied to their skin. A system was in place for recording the site of application. It was not clear however, that one person’s patch application had been rotated in line with the manufacturer’s guidance.

We have made a recommendation that the provider follows best practice in relation to medicines management to ensure people receive their medicines as prescribed and in line with manufacturer’s guidelines.

We spent time looking around the premises and saw that all areas of the building were clean and well maintained. There was a lack of storage space in some of the ensuite bathrooms we viewed.

Safe recruitment procedures were followed. Some people told us that more staff would be appreciated. We observed that staff carried out their duties in a calm, unhurried manner on the days of our inspection.

The registered manager provided us with information which showed that staff had completed training in safe working practices. Evidence of nurses’ clinical skills and competencies was not always available. The registered manager told us that this was being addressed. We did not have any concerns about the skills of nursing staff.

People received suitable food and drink to meet their needs although menus did not always reflect best practice guidelines.

We observed positive interactions, not only between care workers and people, but also other members of the staff team. End of life care was delivered in line with evidenced based practice.

An activities coordinator employed to help meet the social needs of people. A varied activities programme was in place.

There was a complaints procedure in place. Feedback systems were in place to obtain people's views. Meetings and surveys were carried out.

A number of checks were carried out by the registered manager. These included checks on health and safety, care plans, infection control and medicines amongst other areas.

Our observations and findings during the inspection confirmed there was now an effective quality monitoring system in place.

This inspection took place on 24 and 30 August 2016 and the first day was unannounced. This means the provider did not know we were coming. We last inspected Pavilion Court in June 2015. At that inspection we were following up on two breaches of regulations which had been found in our previous inspection in January 2015.

Pavilion Court is a care home which provides nursing and residential care for up to 75 older people, including people living with dementia. There were 42 people living in the home at the time of this inspection.

The service did not have a registered manager. The registered manager had left since our previous inspection and although a new manager was in post they had not applied to become the registered manager at the time of this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were kept safe from harm. Staff were aware of the different types of abuse people might experience and of their responsibility for recognising and reporting signs of abuse. People and their relatives told us they felt safe.

Staffing levels were calculated based on dependency levels and expected staffing ratios. They were reviewed on a monthly basis and on paper appeared appropriate. However during the inspection we observed there were not sufficient staff to provide people with the assistance they required promptly. We have made a recommendation about this.

Possible risks to the health and safety of people using the service were assessed and appropriate actions were taken to minimise any risks identified. People were assisted to take their medicines safely by staff who had been appropriately trained.

Staff were not always provided with sufficient information to enable them to administer topical medication effectively. Clear records were not being kept of the reasons for non-administration of this medication. We have made a recommendation about this.

Staff had been provided with regular training and support to assist them in performing their roles effectively.

Care plans we viewed were evaluated on a regular basis but not always updated in a timely manner. There was limited evidence of people and their family members being involved in care planning. The manager had already recognised this and started to take action to resolve this through working with other staff members to develop a process for reviewing all care plans in conjunction with people and their family members.

The service had not regularly sought feedback from people about the service. This was something the manager had identified and was taking action to resolve at the time of the inspection.

The provider’s complaints policy and procedure were very prescriptive and although the complaints we viewed had been dealt with appropriately we found these had not been responded to in accordance with the provider’s policy and procedure. We have made a recommendation about this.

The service did not have a permanent team of qualified staff in place to support people. People, their friends and family members and external healthcare professionals told us this meant the care people received was not always consistent. The manager was already aware of this issue and had taken steps to recruit permanent qualified staff and reduce agency usage.

The service did not have an activities programme in place. During the inspection we saw limited evidence of activities for people using the service. People we spoke with told us they did not always receive support to maintain their hobbies and interests.

The manager had only been in post since May 2016. Staff spoke positively of the impact she had on driving improvement in the service although they told us they did not always find her

We carried out an unannounced comprehensive inspection of this service on 7, 8 and 15 January 2015. Two breaches of legal requirements were found.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of regulations relating to the maintenance of appropriate standards of cleanliness and hygiene; and the arrangements for ensuring staff were suitably supported by means of supervision and appraisal.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pavilion Court on our website at www.cqc.org.uk.

We found the provider had met the assurances they had given in their action plan and were no longer in breach of the regulations.

The standards of cleanliness and the control of infection had improved since the last inspection and were of an acceptable standard. The home had been completely refurbished. Clearer systems for allocating and checking the work of the domestic staff team had been introduced. We found no cleanliness or infection control issues in our tour of the building. People, relatives and staff told us there had been significant and sustained improvements in these areas.

The support given to workers in the service had improved. The supervision and appraisal of staff members had been planned in advance for the year. Senior staff had been given delegated responsibilities in this area and had been given training in effective supervision and appraisal. Records showed the service was on course to meet its policy for the giving each staff member four supervision sessions and one appraisal meeting each year. Staff told us they felt better supported and felt they could raise issues in these meetings.

We found that improvements had been made to the safety and suitability of the building since our last inspection. The home had no unpleasant odours. Floor coverings had been replaced in some areas of the home, storage problems had been solved and new signs put in place to help people find their way around the home. A major refurbishment of the home had been planned and costed, and was due to be completed by the end of July 2014.

Improvements had been made to the quality of the records kept regarding people's medicines; and storage of confidential records made more secure.

We decided to visit the home at 6am to gain a wider view of the service provided. This was part of an out of normal hours pilot project being undertaken in the North East region.

Some people who used the service had complex needs which meant they could not share their experiences. We used a number of methods to help us understand their experiences, including carrying out an observation, speaking with people who could share their experiences and speaking with visiting relatives.

During our observation we saw people were treated with consideration and respect. Relatives told us they were happy with the care which was provided. One relative said, "I’ve been very impressed with the staff, they deserve a medal. Usually my mum isn’t really interested in food. But she’s been eating well since she’s been here and she’s managed to put on weight."

We reviewed six care records and saw that people's preferences and care needs had been well documented. Staff were knowledgeable about the people's care needs and what they should do to support them.

There were enough staff to meet people’s needs and appropriate arrangements were in place to manage medicines.

However we saw that care was provided in an environment that was not adequately maintained and records were not kept securely.

People told us they were given a good degree of choice in their daily living. They gave us examples such as being able to choose what they ate and drank; what they wore; when they went to bed and got up; and whether to have their bedroom doors open or closed.

One person commented, “Staff are helping me get more independent”.

People said that they were very happy with their care, and spoke highly of the manager and all the staff. They said they were treated with respect. One told us, “I’m well settled, here, and I’m well looked after. Staff help me if I need it”.

People in the home were smartly dressed and well presented. We saw that relationships between staff and people living in the home were affectionate and positive. Staff were caring, patient, sensitive and showed good communication skills.

People told us they felt that staff listened to them and did what they asked of them.

Another person told us that the staff and residents were very friendly, and that it was a happy home.

Visiting relatives told us their family member was happy in the home and was well cared for. They said the staff were “lovely”.

We spoke with people who use the service and with relatives. Two of the people we spoke with said they were aware they had a care plan but told us they had not wanted to see it. They told us they were happy with the way staff discussed the contents with them when any changes were made. One relative we spoke with said she had been "very impressed by the care their relative had been given”. Another relative said she was involved in the process of assessing her aunt’s care needs and felt the staff at the home got to know her extremely well. These were reflective of the overall comments received from people living at Pavilion Court. They said they felt able to speak up when things needed changing and the manager and staff do listen. People living in the home were asked about the food and the responses were very positive. One said "it's lovely and I get what I like" another said “more than enough food to eat here”. People said they liked how the manager knows all of their names, and the care staff always made sure any concerns were passed to the senior staff members if they could not resolve it easily themselves. One said they were "happy any problems would be sorted out" and any complaint or concern would be taken seriously by the service. No one we spoke with had needed to use the complaint process.

This inspection was carried out over three days on 7, 8 and 15 January 2015. The first visit was unannounced. The home was last inspected in September 2014, when we found breaches of seven regulations regarding meeting nutritional needs; safeguarding people from abuse; staffing; supporting workers; assessing and monitoring the quality of service provision; notification of incidents; and records.

Pavilion Court is a care home which provides accommodation and personal or nursing care for up to 75 older people, some of whom are living with dementia. There are four separate units, two of which accommodate people with general nursing and residential care needs; and two which accommodate people who have nursing care needs and are living with dementia. There were 51 people living in the home at the time of this inspection.

The home did not have a registered manager in post at the time of our inspection. The previous registered manager resigned in November 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. An acting manager was in post. This person told us they were in the process of applying to be registered with the Commission.

Systems for recognising and reporting abuse or suspected abuse had improved. Staff were clear about their own personal responsibility to report any incidents of potential or actual abuse immediately. The acting manager had reported four such incidents to the appropriate authorities since our last inspection. People told us they felt safe in the home, and knew how to report any concerns they had.

The ratio of staff members to people in the home had increased since the last inspection and we saw people were kept safe from harm as a result. The suitability of new staff was carefully checked before they started work in the home. Six new staff had been recruited, to minimise the need to use agency staff and improve consistency of care.

Most areas of the storage, administration, recording and disposal of people’s prescribed medicines were safe. Some improvements were needed in regard to the management of some medicines.

People’s needs were assessed before they started living in the home, to ensure all those needs could be met. People were involved in their initial assessments and their wishes and preferences about their care were recorded. A care plan was drawn up to meet each identified need, and these plans were regularly reviewed to make sure they remained up to date and relevant to the person’s needs.

People were able to access the full range of community and specialist health services, and their health was routinely monitored by staff. Healthcare professionals told us they received appropriate and timely referrals from the service, and staff followed their advice.

Staff were kind and caring in their interactions with people, and we saw many instances of sensitive and person-centred care. Most people we spoke with were happy with their care and felt their needs were met. Staff were respectful and ensured that people’s comfort and dignity was maintained. We also found that, at times (particularly mealtimes), people’s care was not delivered in an organised and personalised manner, and that some staff lacked the skills necessary to meet the needs of people living with dementia. Health professionals told us the knowledge and skills of the staff team were variable.

A full staff training programme was in place, but staff were not being given the support they needed to carry out their duties, as they had not received appropriate supervision or appraisal of their work.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005. These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. We saw the acting manager had submitted appropriate applications to the local authority for authorisation to place restrictions on certain people’s movement, in their best interests.

People told us they knew how to make a complaint. Concerns and complaints were responded to in a professional manner.

An enthusiastic activities co-ordinator organised a range of group activities and had good knowledge of individuals’ social preferences, hobbies and interests. However, this information was not always shared with the whole staff group which meant there was not a team approach to meeting people’s social care needs. Some people told us their social care needs were being met.

We noted an improved atmosphere in the home since the previous inspection and a clearer sense of direction. However, we found that there was a lack of cohesion in the staff team, and that roles and responsibilities were still not always clearly understood.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to safety, availability and suitability of equipment; and maintaining appropriate standards of cleanliness and hygiene. You can see what action we told the provider to take at the back of the full version of this report.

The breach in relation to supporting workers was ongoing. This is being followed up and we will report on any action when it is complete.